MEDICARE: DYNAMIC PHYSICAL THERAPY ORTHOPEDIC SPINE AND SPORTS, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	1193323	TX

General Provider Information

NPI Number	:	1295156792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DYNAMIC PHYSICAL THERAPY ORTHOPEDIC SPINE AND SPORTS, PLLC

Provider Business Mailing Address
First Line	:	203 E COLLEGE AVE
Second Line	:	SUITE A
City	:	DEVINE
State	:	TX
Zip	:	78016-2919
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	203 E COLLEGE AVE
Second Line	:	SUITE A
City	:	DEVINE
State	:	TX
Zip	:	78016-2919
Country	:	US
Telephone Number	:	830-663-5397
Fax Number	:	830-663-5359

Authorized Official
Title or Position	:	PRESIDENT/PHYSICAL THERAPIST
Name	:	MARTIN NOYOLA
Credential	:
Telephone Number	:	210-643-7259

Provider Enumeration Date	:	12/31/2013
Last Update Date	:	07/07/2014

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